Intubation in a Patient with Extensive Oral Submucous Fibrosis

Abstract

Oral submucosal fibrosis is a chronic, complex, irreversible, highly potent pre-cancerous condition characterized by juxta-epithelial inflammatory reaction and progressive fibrosis of the submucosal tissues. As the disease progresses, the jaws become rigid to the point that the sufferer is unable to open his mouth [1,2]. The condition is linked to oral cancer and is associated with areca nut chewing and tobacco chewing, which is practiced predominately in Southeast Asia and India. Intubation in patients with extensive submucosal fibrosis is an anaesthetic challenge, more so without the aid of fibreoptic bronchoscope. A 55 year old male with deformed lower lip and restricted mouth opening came for preanaesthetic checkup. Patient had history of carcinoma lip which was operated twice, over a span of 3 years followed by cycles of radiotherapy for 2 months and was posted for lower lip reconstruction surgery. On examination of airway, mouth opening was ½ finger because of extensive submucosal fibrosis. Sternomental, thyromental and mentohyoid distance were normal. Lower incisors were missing [Fig.1]. All the routine investigations were within normal limit. We planned for awake nasal intubation and informed consent was taken from the patient. Preparation for emergency tracheostomy if required was done. Premedication was done with glycopyrollate and midazolam. Both nostrils were prepared with vasoconstrictive drops. Topical lignocaine 4% solution was applied to the nasal mucosa and sprayed in oral cavity. A 7.5 mm cuffed endotracheal tube (ETT) lubricated with lignocaine gel was introduced into the right nare with patients head in sniffing position. Air movements were continuously felt and Fig.1: Patient with restricted mouth opening.